In 2021, Americans wagered $53 billion at casinos and sportsbooks, beating the 2019 record by 21 percent and setting a new benchmark for what is now an almost-nationwide gaming industry. Come Super Bowl Sunday, U.S. sports fans could bet a whopping $7.61 billion on a single game.
Win or lose, for most people, betting is a fun, harmless diversion. Sometimes it will leave them lighter in the wallet, but the loss is momentary, without lasting impact.
Then there’s a small percentage of the population for whom gambling is chronic, an irresistible compulsion with potentially disastrous effects on finances, family relationships and employment.
If those gamblers choose to quit, they can find help in support groups, therapy, and in some cases, inpatient rehab. The website of the National Institutes of Health says the most successful therapeutic protocols are cognitive-behavioral therapy (CBT) and “motivational interviewing,” a goal-directed therapy to get past the denial that keeps gamblers stuck in their behavior.
“Very few of us went from zero to 100 miles an hour in our addictive disorders,” says Ted Hartwell, consultant to the Nevada Council on Problem Gambling, and a recovering gambling addict. “We ‘practiced’ in a sense over time, developing rationalizations around those behaviors. Those things can be unlearned through talk therapy and CBT.”
While the methods have helped untold numbers of gamblers, including Hartwell, they don’t work for everyone, and they don’t reach the vast majority of problem gamblers who, for various reasons, never seek help at all. So research scientists are working to find new treatments to help more people —and new ways to put those solutions within easy reach.
Because the federal government currently doesn’t fund research into gambling disorders, the emphasis has been on treatments for depression and anxiety, which often co-occur in problem gamblers.
Take naltrexone. Originally prescribed to treat alcohol abuse and then drug abuse, the narcotic agonist has shown promise as an off-label treatment for compulsive overeaters and compulsive gamblers. It works by blocking the “positive” effects of these substances and behaviors, in effect removing the kick or high a user gets when indulging.
“The same reward system is at work, so things that seem to work for alcohol and drugs might work for gambling,” says Christine Reilly, research director at the International Center for Responsible Gaming (ICRG), which funded the original research into naltrexone. “An estimated 75 percent of people with gambling disorder have preexisting conditions like anxiety, depression or substance use, so it’s very difficult to attack the gambling problem unless you deal with the comorbid disorder.”
Another medication that could help: ketamine, approved in 2019 by the federal Food and Drug Administration (FDA). The antidepressant is fast-acting and relieves symptoms in hours instead of weeks or longer.
“If you have to wait six weeks for an antidepressant to start working, that’s too long,” says Reilly. “We’re very concerned about people who are at risk for suicide, and have to move more quickly for people who may be in crisis.”
Ketamine’s long-term efficacy is still unknown, which raises the questions: “If people need to keep going back, how expensive will it be? Will insurers pay for it? We don’t know,” says Reilly. “But if it shows promise for depression, anxiety and other addictions, some scientists will be coming to us for money to test some of these things. And we’re totally open to any innovative approach to treatment.”
Likewise, psilocybin, with active ingredients from “magic mushrooms,” is being studied as a possible treatment for depression, drug abuse and post-traumatic stress disorder, and also could help people with gambling disorder.
“We do have medications that reduce some of the urges and intensity of the cravings” associated with gambling disorder, says Timothy Fong, MD, associate clinical professor of psychiatry at the University of California, Los Angeles. “We’re constantly looking at things that could make a difference.
“The real question is, why don’t we try these things out? Well, clinical trials are expensive and time-consuming, and we just don’t have the research support infrastructure (for gambling disorder) that we have for other diseases. That doesn’t mean there aren’t new treatments that could work. It means we haven’t been able to prove they work.”
People who use psilocybin, for example, “don’t feel the need, the urge, the itch to escape through drugs or addiction,” reports Fong, who’s studied gambling disorder for 20 years. “They don’t get triggered to the point where they’re constantly thinking about gambling. They can tolerate stress better, and don’t automatically seek gambling as a way of soothing themselves.”
There’s a hitch. At the federal level, psilocybin, like MDMA, LSD and heroin, is a Schedule I controlled substance. But like cannabis, which falls into the same category, its potential medical value may eventually get it to the marketplace, at least on the state level (only Oregon has decriminalized psilocybin mushrooms and legalized them for therapeutic use). For now, for most Americans, that solution is out of reach.
The Treatment Cocktail
With no magic bullet for problem gambling, experts recommend a “cocktail” approach—a tailored mix of therapy, medication and peer support. Taken together, they may give gamblers a greater understanding of their condition and a level of symptom relief that gets them closer to recovery.
Hartwell agrees that the best longer-term outcomes are associated with a combination of treatments: CBT or motivational interviewing along with “some type of sustained maintenance program afterwards, like a 12-step or other recovery group therapy. The intensive outpatient program I went through has a weekly aftercare meeting that, 15 years-plus later, I occasionally check in with,” he says.
While researchers hunt for new treatments, Fong advocates making traditional methods more widely available online and via teletherapy, and training more therapists to detect the signs and symptoms of gambling disorder.
Online gambling increased during the pandemic, and so did the kind of services offered by Kindbridge Behavioral Health, which specializes in the virtual treatment of compulsive gambling. It can help many gamblers by removing the internal and external obstacles to treatment.
“Just the thought of getting out of bed, getting dressed, going to the doctor’s office, finding a parking space—sometimes it’s just too much” for someone likely grappling with depression as well as gambling addiction, says Reilly. “Whereas with telehealth, you just get to your computer, turn it on, and you do your session.”
“You can be anywhere in America and get an online therapist” through services like Kindbridge, agrees Fong. “You don’t have to get on a waiting list. You can access care much more quickly than even five years ago. Another thing we’re really looking at is how to build out digital apps and digital health products to help people manage their gambling.”
He points to Gamban, a software blocker that prevents people from accessing gambling websites on all their devices. “You may say, is that treatment or just putting up a fence? But anything that lengthens the time before a person actually starts gambling is a good thing and could be considered a part of treatment.”
One day, he says, there may be apps, akin to fitness trackers and smartphone-compatible medical devices, that recognize when a person is feeling the urge to gamble and even notifies them if they’re getting too close to a physical casino. “We’re not there yet, but that’s where we’re headed.”
Peer support will always be an important part of that treatment cocktail. Gamblers Anonymous meetings, faith-based and otherwise, let sufferers see that recovery is possible, and that they’re not alone in their struggle. The online support group Gamblers, Family and Friends in Recovery (GFFR), which launched during the pandemic, offers 400 Zoom meetings a week, 24 hours a day.
Then there’s the concept of “sober companions,” which originated among the Hollywood elite and now is becoming more mainstream, if not widespread.
“These are men and women who actually help you execute your recovery plan,” says Fong. “I have a patient who’s struggling with a local casino. Every week she gets free play offers and enticements to go play. She can’t cancel her player’s card—she’s tried; it’s just too hard emotionally. So a recovery companion would actually go with her to the casino, set up a time to meet with a host and ensure that her account is shut down.”
Sober companions also support the client in replacing destructive habits with healthy ones: exercising, hobbies, learning new skills, “all the things that are part and parcel of recovery that often are really hard to do on your own,” says Fong. “It’s like a residential treatment program without walls.
“Addiction takes a village to recover from. These sober companions are kind of like that village, but it’s not something that insurance will pay for.” In addition, sober companions aren’t licensed or regulated.
A website called Your First Step to Change, part of the Cambridge Health Division on Addictions, funded in part by the ICRG, is an example of a “brief intervention.” By recognizing the ambivalence of gamblers who may not be fully committed to treatment, but are considering it, “maybe it can help more people,” says Reilly. “We need to do a better job of putting a lot of self-help interventions on the internet.”
According to the site, which offers tools in five languages, visitors can evaluate their addiction-related behavior and “develop change strategies, should they decide that change is the best course.”
TMS, ECT, Et Cetera
One innovative approach is transcranial magnetic stimulation (TMS), also FDA-approved for treatment-resistant depression, and possibly indicated for gambling disorder too.
During a series of up to 30 TMS sessions, an electromagnetic coil is placed against the patient’s scalp. The coil then painlessly delivers a magnetic pulse that stimulates parts of the brain that regulate mood. The patient is awake during the procedure, and the side effects (headaches, muscle tension) are typically minor and of short duration. The benefits are sometimes felt after just a few sessions.
According to the Mayo Clinic, many TMS patients “experience an increase in mood, energy and appetite, while also experiencing a reduction in anxiety. A reported 83 percent of people who undergo TMS experience improvements, and 62 percent achieve complete remission from their depression.”
“We do TMS for smoking cessation, cocaine addiction, things like that,” says Fong. “Because we view gambling disorder as an addictive disorder, it stands to reason that treatments that work for those conditions may also work for gambling.”
Perhaps the gold standard for unremitting depression is electroconvulsive therapy (ECT), once known as electroshock therapy. ECT has an unfortunate reputation; the term alone conjures images of unwilling patients strapped to gurneys, electrodes attached to their skulls like Frankenstein. Most people don’t willingly sign up for the treatment, despite its track record of success.
Meanwhile, it’s encouraging to Hartwell that an estimated 30 percent of people, “both in the substance realm and in the gambling realm,” find a way to recover on their own, without treatment or outside intervention.
“They have built-in resiliency factors or protective factors that allow them to do that. Beyond that, there’s a spectrum of individuals who may go to 12-step meetings and that’s all they need, and maybe they don’t do that forever. Some even choose to return to some type of controlled gambling.
“There’s evidence for a kind of fluidity, from at-risk and problem gambling back to controlled gambling. A lot of people see (gambling disorder) as this chronic and progressive illness for everyone, and that doesn’t seem to be the case.”
Hartwell chooses “to stay abstinent today. When I start to get a little bit intrigued or have what I call feelings of nostalgia for when I used to play poker, I see that as a warning sign. It’s enough for me not to take that risk.”
Of course, the tried-and-true modalities are as relevant as ever; it’s just a matter of making them available to those in need.
“By getting more therapists from different backgrounds up to speed and updated about what gambling addiction is and is not, that’s how we expand treatment options,” says Fong. “It’s not coming up with a new treatment style. It’s coming up with more ways to get gamblers into existing treatment styles.” When that happens, he says, “suddenly you have more client choice.
“It’s never going to be one thing, just a simple pill or like a 60-minute thing you do with a therapist. It’s more about having options throughout the day and night to help combat whatever signs and symptoms of gambling show up, when they show up.”
And they show up regularly. In a recent Google search for 1-800- GAMBLER, the website of the Council on Compulsive Gambling of New Jersey, the target site came in second to an ad for “New Jersey’s No. 1 online sportsbook: BetParx.”
Congresswoman Seeks Federal Funds for Gambling Disorder Research
Though the federal government reaps some of the tax benefits from gambling, it currently offers no funding for research, treatment or public awareness about gambling disorder, compared to the billions it spends on substance use disorders, including dependence on alcohol, tobacco and drugs.
U.S. Rep. Claudia Tenney (R, New York) supports legislation that would change that. Through the proposed Gambling Addiction Recovery, Investment and Treatment Act (GRIT), the federal government would levy an excise tax of 0.25 percent on all money wagered on sports in the U.S., then set aside half. Seventy-five percent of the pot would go to states for gambling disorder prevention and treatment; the rest would be used for research.
According to the National Council on Problem Gambling, the funds would provide “vital support to state health agencies and nonprofits left on their own to address gambling problems,” and “allow investment in best practices and comprehensive research, which is only possible at the national level.”
However, reports say the bill makes casinos alone liable for the tax, excluding lotteries, sportsbooks or racetracks. If that’s the case, the legislation is a non-starter, says Alan Feldman, former casino executive and an expert on responsible gaming at the International Gaming Institute of the University of Nevada, Las Vegas.
“Problem gambling policy is a shared responsibility. To add an excise tax to just one segment of the industry is ridiculous, and not reflective of how and why problem gamblers are who they are,” says Feldman.
“There’s a common misperception among regulators—around the country, around the world—that without casinos, there is no problem gambling. But as a rule, problem gamblers tend to wager on three to four different kinds of gambling activities—parimutuels, the lottery, slot machines and table games. It’s a problem when it’s a problem.”
Feldman might support a bill that shares the tax burden among all gambling outlets. “The federal government is woefully behind on this topic. It should have been funding research years and years ago, because certain kinds of research can only happen with federal money.”
He adds that current research studies are based on too little data, which “won’t provide the level of accuracy and clarity” needed to draw solid conclusions about gambling disorder, its causes and potential treatments. “There are certain things you can do mathematically to validate the research, but the error rate in small studies is higher.”
A representative from Tenney’s office noted that the bill has not yet been introduced, is still in its “very early” stages, and is open to revision based on comments from stakeholders in and out of the gaming industry.
Meanwhile, recovering problem gambler Ted Hartwell supports legislation to make federal funding available to the scientific community. “As gambling becomes more accessible and at our fingertips, and our phones become our gambling devices, we need to be very proactive, both from a legislative standpoint and a public awareness standpoint, of the potential impact and collateral damage for those of us who experience problems in this area, and provide resources to address this public health issue.
“We need to get folks from across the aisle to make this successful.”